DRG - Casemix funding in health care

What is DRG?

-Automatic translation

DRG is designed to classify patients according to the services' required resources. The system is based on the fact that similar health services form groups with similar diagnoses and treatment needs that bear similar costs. These groups are called DRGs. The classification is based on information from medical records, i.e., diagnoses, procedures and other relevant data related to patient demographics.

The DRG classification is a secondary classification system since it is based on other basic classification systems: classification of diagnosis, ICD-10 and classification of procedures, NCSP-IS.

The DRG classification consists of over 870 groups. The classification rules can become complex; for example, many side effects/complications may only affect some primary diagnoses and not others. Thus, coordination and accuracy in documenting diseases and procedures is a vital issue.

-Automatic translation

Main Diagnosis Categories (MDC) are a rough classification of all major diagnoses, but within each category, you can find diseases from specific organ systems or diseases of a particular type. Each inpatient stay or outpatient visit is assigned to one of the 25 main diagnosis categories of the system.

Main Diagnosis Categories tend to belong to specific medical specialities. For example, DRG groups for neurological diseases are in the main diagnosis category 1 (diseases of nervous system), and infectious diseases are in the main diagnosis category 18 (infectious and parasitic diseases).

01 - Diseases of nervous system
02 - Diseases and disorders of the eye
03 - Diseases and disorders of the ear, nose, mouth and throat
04 - Diseases and disorders of the respiratory system
05 - Diseases and disorders of the circulatory system
06 - Diseases and disorders of the digestive system
07 - Diseases and disorders of the hepatobiliary system and pancreas
08 - Diseases and disorders of the musculoskeletal system and connective tissue
09 - Diseases and disorders of the skin and subcutaneous tissue
10 - Endocrine, nutritional and metabolic diseases and disorders
11 - Diseases and disorders of the kidney and urinary tract
12 - Diseases and disorders of the male reproductive system
13 - Diseases and disorders of the female reproductive system
14 - Pregnancy, childbirth and puerperium
15 - Newborns and other neonates with conditions originating in the perinatal period
16 - Diseases and disorders of the blood and blood forming organs and immunological disorders
17 - Myeloproliferative diseases and disorders, poorly differentiated neoplasms
18 - Infectious and parasitic diseases
19 - Mental diseases and disorders
21 - Injuries, poisonings and toxic effects of drugs
22 - Burns
23 - Factors influencing health status and other contacts with health services
24 - Multiple significant trauma
30 - Breast problem
98 - Diseases and disorders of male/female reproductive organs
99 - Unspecific or erroneous information

-Automatic translation

Each inpatient stay or outpatient visit can only be in one of the DRG groups of the classification. If the diagnosis or treatment code change in the documentation it can effect the grouping so that the inpatient stay or outpatient visit moves from one DRG group to another.

DRG groups are about 870, of which about 570 are for inpatient stays and about 300 are outpatient, daypatient, or short visits.

The code of groups is usually a three-digit number; some DRG groups have subcategories indicated by a letter (C, F, G), e.g. 209C - Major joint secondary procedure on hip.

The day-surgery service groups are indicated by the letter O (Outpatient) at the end of the code. DRG-O is a classification for daypatients, short outpatient visits, and short-term inpatient stays, where the patient is admitted and discharged on the same day. Each DRG group has a specific weight that is determined by the Ministry of Health each year (Icelandic).

Examples of codes and names of DRG groups:

004 - Spinal procedures
116O - Implantation or replacement of cardiac defibrillator, short therapy
209C - Major joint secondary procedure on hip
209F - Major joint secondary procedure on knee/ankle
209G - Major joint primary procedure on knee/ankle

-Automatic translation

The so-called error groups of the DRG system are 20 in total and weight 0. Inpatient stays or outpatient visits go into an error group if there is a problem with the documentation, for example, if a primary diagnosis is missing or if the person is too old for a particular diagnosis. Monitoring of the error groups within the DRG is necessary.